1. May, 2007 Moving to a Health Agenda with High Return on Investment (ROI) High Reach / Low Cost Interventions Jim Grizzell, MBA, MA, CHES, HFI, FACHA Policies Health Communication, Ecological / Environmental Approach, Social Marketing Activities no feedback Health Systems Activities w/ Health Education Specialty Care Community & Neighborhood Collaboration Primary Care

2. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions2 Moving to a Health Agenda  Intervention Pyramid (slide 3) High Reach / Low Cost vs Low Reach / High Cost  Creating a Health Agenda (slides 4 – 7)  Historical Trend (slide 8)  Evolution of Wellness Programs (slide 9)  Cost-Effectiveness & Return on Investment Program and Intervention Levels of Interventions and Return on Investment (ROI)  Chart (slide 10)  Example (slide 11) Population-Based Social Marketing Media Campaign vs Willing Volunteer (People voluntarily attend classes)

3. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions3 There is cost-effective health at the bottom of the pyramid Think High Reach / Low Cost High Low Cost High Low Reach Policies Health Communication, Ecological / Environmental Approach, Social Marketing Activities no feedback Health Systems Activities w/ Health Education Specialty Care Community & Neighborhood Collaboration Primary Care

4. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions4 Recommendation to Create a Health Agenda Two Key Elements 1. Health promotion leaders must inform and motivate  the public, the people who benefit from prevention, and  policymakers about the power of prevention and health promotion to increase longevity and improve quality of life. McGinnis, J., Williams-Russo, P. and Knickman, J. The case for more active policy attention to health promotion. Health Affairs. 2002;21:2. 78-93.

5. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions5 Recommendation to Create a Health Agenda Two Key Elements 2. We must create regulatory strategies and financial incentives to facilitate social, behavioral and environmental change.  Examples  taxes on high fat and sugar foods  grants-in-aid to encourage communities to develop bike paths (ecological approach)  social marketing  direct regulation (policy)  indirect regulation through the legal system (i.e., law suits against false advertising) McGinnis, J., Williams-Russo, P. and Knickman, J. The case for more active policy attention to health promotion. Health Affairs. 2002;21:2. 78-93.

6. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions6 Recommendation to Create a Health Agenda Two Recommendations from the Institutes of Medicine 1. “A better balance is needed between  the clinical approach to disease, presently the dominant public health model for most risk factors, and  research and intervention efforts that address generic social and behavioral determinants of disease, injury and disability.” 2. Focus interventions on social and behavioral factors should link multiple levels of influence (i.e., individual, interpersonal, institutional, community, and policy levels)  Rather than focusing interventions on a single or limited number of health determinants Smedley, B. and Syme, S. Promoting health: intervention strategies from social and behavioral research. 2000. Washington: National Academy Press. Available at http://www.nap.edu/books/0309071755/html/ Accessed May 20, 2004.

7. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions7 Recommendation to Create a Health Agenda Link to College Health  “Nationally, there is an imbalance of investments in medical care compared to health promotion and disease prevention activities This imbalance is true for most college health programs The fact that the top health impediments to successful academic performance are driven by conditions that are preventable ought to draw attention to policy opportunities for promoting health in the student population.” Grizzell, J., The university learning mission, college health and the health agenda. NASPA NetResults, Research. March 25, 2005. Accessed on April, 10, 2007 at www.naspa.org/membership/mem/nr/article.cfm?id=1486, www.csupomona.edu/jvgrizzell/hppolicy/think_health_agenda.pdf www.naspa.org/membership/mem/nr/article.cfm?id=1486

8. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions8 Historical Snapshot: Think Health Agenda & Business Case Corporate & College Health & Wellness 1850s 1970s 1980s ~1995 2010 Recreation Fitness Health Promotion HPM* 1 st Generation 2 nd Generation 3 rd Generation 4 th Generation Instruction, Treatment, Exercise Health Education > Promotion HAPM* 1 st Generation 2 nd Generation 3 rd Generation * Health & Productivity Management, Health & Academic Performance Management

9. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions9 Business Case Evolution of Health & Wellness Results / Outcome Oriented Health and Academic Performance Management * = Health Cost Management, NOTE: chart adapted from Chapman, see notes section for reference. Add focus on student learning Strong risk reduction Strong high risk focus Some required activity Site and virtual Strongly personal (individual, group) Major incentives Sig. others served Rigorous assess/eval Traditional Medical and Health Promotion Traditional Medical Model and Health Education Mostly health focus Some risk reduction Little risk reduction Limited HCM oriented All voluntary Site-based only Weak personalization Modest incentives Few sig. others served Weak assess/eval Fun activity focus No risk reduction No high risk focus Not HCM* oriented All voluntary Site-based only No personalization Minimal incentives No sig. others served No assessment/eval Activity Oriented Morale Oriented Name of Model Main Features Primary Focus

10. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions10 Business Case Levels of Interventions & Wellness Program ROIs Program Levels Intervention Levels Quality of Life Traditional Health & Productivity I. Awareness Information, no feedback <1:1 IIa. Behavior Change Health education w follow-up 3:1 IIb. Behavior Change Targeted priority health issues with Social Marketing 6:1 to >15:1 III. Supportive Environment Ecological Approach, Policies >15:1

11. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions11 Business Case High Reach / Low Cost vs Low Reach / High Cost  Population-Based Environmental Support Program Social Marketing Mass Media Campaign $294* x 4,500** = $1,323,000 Return on Investment = 4.4:1 (cost is less than benefit)  Willing Volunteer Behavior Change Program People voluntarily attend classes $294* x 250 = $73,500 Return on Investment = 0.73:1 (cost is greater than benefit) * Johnson & Johnson health care costs avoided for each employee that gets regularly physically active ** WHEELING WALKS: a media-based intervention to increase walking. Bill Reger-Nash, EdD, www.americawalks.org/PDF_PAPE/Reger.pdf

12. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions12 Questions? High Low Cost High Low Reach Policies Health Communication, Ecological / Environmental Approach, Social Marketing Activities no feedback Health Systems Activities w/ Health Education Specialty Care Community & Neighborhood Collaboration Primary Care

13. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions13 Employee Wellness Business Case Six Core Program Cost (Percent) Areas Medical $4,670 (37%) Turnover $3,700 (29%) Unscheduled Absence $810 (6%) Non- occupational Disability $513 (4%) Presenteeism $2,590 (21%) Worker’s Compensation $310 (3%)

14. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions14 Employee Wellness Business Case A Seventh Core Program Cost Area  Health, Productivity & Absenteeism Management Health and Occupational Risk/Needs Assessment Health Promotion and Disease Prevention Program  Smoking cessation  Stress/depression/mental health  Heart and diabetes disease management Employee assistance program Environmental health and safety  Cost $70 - $150 per employee  Benefit =/> $210 - $450 per employee

15. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions15 Positive ROI (=/>$3:$1) Increased productivity Reduced health care costs Risk reduction (employees with fewer risks) Improved attitudes & behaviors Teams & Participation (80% of employees) Commitment (set organization & individual goals) Awareness (HRAs, Group & Individual Reports, ≈80% of employees) Increased knowledge (educate managers & employees) Teams and Program Coordinator Senior Management Support Sequence of Critical Success Factors

16. Moving to a Health Agenda with High ROI High Reach / Low Cost Interventions16 Positive outcomes and ROI Reduced utilization Reinforcement Management: Finding intrinsic and extrinsic rewards for new ways of working; Environmental Reevaluation: Appreciating that the change will have a positive impact on the social and work environment; Self-Liberation: Believing that a change can succeed and making a firm commitment to the change Self-Reevaluation: Appreciating that the change is important to one’s identity, happiness, and success Dramatic Relief: Emotional arousal, such as fear about failures to change and inspiration for successful change Consciousness Raising: Becoming more aware of a problem and potential solutions Processes of Change